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Esophagectomy or Esophagogastrectomy
=Introduction= This procedure may be done either before or after chemo and or radiation. In addition, it can be performed for high-grade dysplasia (no invasive carcinoma), and therefore a gross mass may not be readily identified. The questions to be addressed are: *Is there any tumor? If treated, is there residual tumor? *Is the tumor primary or metastatic? *What is the depth of invasion? *Are there metastases? *Are the margins free of tumor or dysplasia? *Is there intestinal metaplasia? *Is there nodal involvement? Barrett's mucosa (intestinal metaplasia) is pale pink-red and finely granular. It is distinct from the squamous mucosa which is white, smooth and glistening. It is usually found close to the GE junction, but can occur elsewhere. Adenocarcinoma usually presents at or just above the GE juction and is typically tan-pink, polypoid, and may be ulcerated. These tumors may tunnel underneath the overlying uninvolved mucosa and show up on your microscopic sections far from the tumor. Squamous cell carcinoma can occur at any level of the esophagus. They can be fungating, ulcerated or present as diffuse thickening with narrowing of the lumen. =Fresh Handling= #Measurements - length and diameter or circumference of the specimen. #Identify the proximal and distal ends and measure the staple lines. #Is the proximal stomach included? If so, measure the length along the lesser and greater curvature. #Identify and measure the attached fat. #Ink adventitia, (this will be your deep margin underneath the tumor), proximal and distal lines of resection. It is advisable to ink the entire specimen. #Shave proximal and distal margins of resection. Occasionally, the surgeon will ask for a frozen on these, depending on how close the tumor is to the margin. #Open longitudinally on the side away from tumor, if possible. #Photograph the opened specimen. #Pin the specimen to a corkboard and fix overnight. #Diagram or print the digital photograph indicating abnormal areas and source of sections (this will help you and the attending at the time of sign out). =Grossing In= #Describe the specimen first (total, subtotal esophagectomy; presence or absence of portion of stomach), and then the lesions you identify. #Tumor characteristics: ##Size ##Appearance (fungating, rolled edges, ulcerated…) ##Does it involve the entire organ circumferentially? ##Depth of invasion in cm, and extent of invasion on cross section (submucosa, into or through the muscularis propria) ##Extension into stomach and adjacent organs. ##Distance from both lines of resection. ##Can one identify the red, velvety appearance of glandular metaplasia? What is its relationship to the tumor (surrounding entirely, only proximal…) ##Tumor after treatment: Pre-operative radiation may be given to the patient, sometimes making the residual tumor difficult to appreciate grossly. Look for areas of shallow ulceration, thickened wall or irregular, granular appearing squamous mucosa. If a tumor is not readily identified, the entire gastroesophageal junction needs to be submitted to look for residual tumor. ##If there is a history of high-grade dysplasia/carcinoma in situ on a previous biopsy and no tumor is grossly identified: The gastroesophageal junction mucosa should be blocked and submitted in toto and labeled according to a diagram. #Appearance of noninvolved mucosa: ##Is there recognizable esophageal mucosa proximally and, more importantly, distal to the tumor? Is the lumen dilated proximal to the tumor? ##Is the wall thickened? Are there varices? #Stomach, if present ##Features of gastroesophageal junction and of gastric mucosa. ##Where is tumor in relation to GE junction? #Lymph Nodes – Do they appear grossly involved by tumor? If so, how many? You should find at least 10 lymph nodes, most of which are located around the GE junction. This can be difficult in small specimens, where it may difficult to find any. After you have done a thorough examination and you have less than 10, be sure to dictate that in your report, and submit the fat surrounding the specimen. For enlarged lymph nodes which are obviously involved, a representative section is enough. #Sections for histology: see sample dictation below. =Sample Dictation= Specimen number___ is received fresh, labeled with the patient’s name and medical record number and designated (esophagectomy, gastro-esophagectomy). It consists of a portion of (esophagus, esophagus and proximal stomach); the esophagus measuring ___x___x___ cm and the attached stomach measuring ___x___x___ cm. There is a mass/lesion/area of induration present (at the proximal esophagus, at the mid esophagus, at the gastro-esophageal junction) measuring ___x___x___ cm, located ___cm from the proximal margin, ___cm from the distal margin, and ___ cm from the deep inked margin. The mass/lesion is (describe shape, color, texture, depth of invasion). The uninvolved esophageal mucosa is (describe normal or other lesions: normal is glistening, smooth and white, foci of intestinal metaplasia are granular, pale pink-red). The uninvolved gastric mucosa is (describe normal or other lesions: normal is velvety tan-pink). The peri-esophageal/peri-gastroesophageal soft tissue is dissected to reveal ___ potential lymph nodes (comment if the nodes are grossly positive/negative). SECTION KEY: *Representative sections of the tumor are submitted as:____ **Three-four sections of the tumor should be submitted: one in association with adjacent uninvolved proximal esophageal mucosa; one in association with adjacent distal esophageal/gastric mucosa; and two showing the deepest level of invasion. Two sections at least should be full thickness to demonstrate the deep margin. Remember, one section of tumor can sometimes show both association with normal and level of invasion. **If no definitive mass: The area of concern is submitted in toto as: ____ **Submit the entire area with associated proximal and distal normal mucosa. *Proximal esophageal margin is submitted as:___ **Representative section of margin submitted as a shave (en face); (unless mass/lesion and margin can be submitted in one section representative perpendicular section.) *Distal esophageal/gastric margin is submitted as: ___ **Representative perpendicular section of margin closest to tumor. If there is no stomach, the entire distal esophageal margin is submitted. *Uninvolved proximal and distal mucosa submitted as:____ *One transverse section away from the tumor edge, both proximal and distal, if possible. *Uninvolved GE junction submitted as:___ **1-2 sections of the GE junction should be submitted if the resections is for a proximal tumor and the GE junction looks normal. *Potential lymph nodes submitted as: ____ *Other mucosal abnormalities, away from the tumor, submitted as:___ =Review and Signout= The final report must include: *Histologic type - squamous, adeno, etc. *Degree of differentiation. *Depth of invasion. *Lymphatic or vascular permeation. *Number of lymph nodes, indicating number positive for tumor. *Adequacy of margins of resection. *Presence or absence of mucosal alterations of apparently uninvolved mucosa (e.g.: Intestinal metaplasia). *Presence of chemo-radiation treatment effect (fibrosis, vascular wall thickening, mucosal atrophy…). Sample diagnostic lines 1. Esophagus and stomach, esophagectomy: :-(Adenocarcinoma, squamous cell carcinoma), x cm, (well, moderately, poorly) differentiated, invasive into the (lamina propria, muscularis propria, adventitia, adjacent structures), no lymphovascular or perineural invasion identified. :-Proximal esophageal and distal gastric resection margins free of tumor. :-X lymph nodes, no tumor seen (0/X). OR Metastatic (adenocarcinoma, squamous cell carcinoma) in X of Y lymph nodes (X/Y). :-Esophagus with (intestinal metaplasia, high grade dysplasia, ulceration ) :-Stomach with no specific pathologic change. 1. Esophagus and stomach, esophagectomy: :-(Adenocarcinoma, squamous cell carcinoma), (well, moderately, poorly) differentiated, single (multiple) microscopic focus in the (lamina propria, muscularis propria, adventitia, adjacent structures), arising adjacent to esophageal ulcer, no lymphovascular or perineural invasion identified. :-Proximal esophageal and distal gastric resection margins free of tumor. :-X lymph nodes, no tumor seen (0/X). OR Metastatic (adenocarcinoma, squamous cell carcinoma) in X of Y lymph nodes (X/Y). :-Esophagus with (intestinal metaplasia, high grade dysplasia, ulceration, treatment effect). :-Stomach with no specific pathologic change. 1. Esophagus and stomach, esophagectomy: :-Esophagus with (intestinal metaplasia, high grade dysplasia, ulceration) and treatment effect, no residual (adenocarcinoma, squamous cell carcinoma) identified. :-X lymph nodes, no tumor seen (0/X). Or Metastatic (adenocarcinoma, squamous cell carcinoma) in X of Y lymph nodes (X/Y). :-Stomach with no specific pathologic change. ---- Return to Gastrointestinal Grossing